Special Focus on Respiratory Syncytial Virus (RSV) Strategies for Reducing the Risk of Respiratory Syncytial Virus Infection in Infants and Young Children: A Canadian Nurses’ Perspective Marianne Bracht, RN, RSCN Debbie Basevitz, RN Marilyn Cranis, RN Rose Paulley, BN Bosco Paes, MBBS, FRCPI, FRCPC R pneumonia, hospitalization, and even death in preterm infants children by two years of age and is the leading and other high-risk children.2–6 Aside from concerns regardcause of pediatric lower respiratory tract infections (LRTIs) ing acute disease, RSV infection in infancy is a risk factor worldwide.1 A recent systematic for the development of other review estimated that in 2005, a medical conditions later in life. total of 33.8 million new cases Numerous epidemiologic and Abstract of RSV-associated LRTIs were clinical studies have found that Respiratory syncytial virus (RSV) infections are prevalent diagnosed globally in children RSV-induced LRTI in infancy globally and can cause substantial morbidity in infants and ,5 years of age.1 Approximately predisposes children to recurrent young children. The virus is easily transmitted by direct hand-to-hand contact and can lead to serious respiratory 96 percent of these infections Continuing Nursing Education disease and hospitalization, particularly in premature infants occurred among children in (CNE) Credit and children with certain medical conditions. Educating developing countries. In addiA total of 3.1 contact hours may be families with young children, especially those in remote rural tion, an estimated 66,000 – earned as CNE credit for reading the regions, regarding the potential adverse health outcomes of 199,000 children ,5 years articles in this issue identified as CNE RSV infection and measures to reduce the risk of transmitting and for completing an online post-test of age died from severe RSV or acquiring RSV has been a key focus of the health care and e valuation. To be successful the disease; most (99 percent) of learner must obtain a grade of at least system in Canada. Geographic, cultural, and socioeconomic these reported deaths occurred 80% on the test. factors present formidable challenges to the execution of this in nonindustrialized nations.1 endeavor. Therefore, it is critical to develop and systematically Disclosure A lt hough R SV infect ion implement effective educational programs for both families Jamie L. Kistler, PhD, provided medical writing and editorial support to the manifests as mild, cold-like upper and health care providers. In Canada, nurses play a critical authors of this article. She is an employee role in education and counseling. In this review, we share respiratory tract symptoms in of Complete Publication Solutions, our perspectives and suggest empirical practices that may be most full-term infants and older LLC, which received financial support applicable worldwide. from Abbott for the preparation of this children, it can lead to severe article. See the Acknowledgments section LRTIs such as bronchiolitis and espiratory syncytial virus (RSV) affects near ly a ll for full details. Accepted for publication May 2012. N E O N ATA L N E T W O R K VOL. 31, NO. 6, NOVEMBER/DECEMBER 2012 © 2012 Springer Publishing Company 357 http://dx.doi.org/10.1891/0730-0832.31.6.357 wheezing, bronchial hyperreactivity, obstructive sleep apnea, and asthma.7,8 In addition, hospitalization for RSV infection before the age of two has been shown to be an independent risk factor for the development of asthma.9 Although the link between RSV infection and short- and long-term airway obstruction and airway hyperreactivity has been clearly established in animal models,10,11 there is ongoing debate regarding the causal relationship between RSV and asthma in children.12,13 It is likely that several factors play a role in determining the risk for respiratory morbidity, including family history of atopy, genetic predisposition, immune modulation of the airways postinfection, and baseline lung function prior to an LRTI.13–22 Regardless of the underlyig etiology, studies have shown that children infected with RSV are more likely to experience wheezing during their first year of life23 and to develop recurrent wheezing by six years of age.24 Although wheezing generally resolves during adolescence,24 features of asthma may persist until 18 years of age.25 In addition to respiratory morbidity, RSV infections are associated with a negative impact on children’s overall health-related quality of life26,27 and a significant increase in health care resource use and mortality. 28 The impact of RSV-associated hospitalizations on the emotional well-being of the family is also substantial. Levels of stress and anxiety have been shown to increase among caregivers of patients hospitalized for RSV disease, with these effects extending as long as 60 days posthospitalization.27 This stress may be attributed to several factors, including caregiver response to the child experiencing symptoms of RSV infection; anxiety and concern regarding the child’s admission to a pediatric intensive care unit (PICU) or diagnostic or treatment procedures the child must undergo; separation of the child from the home and family during the hospital stay; and disruption of daily routine and sleep schedule.27 Direct and indirect costs of RSV-associated hospitalizations, including time and financial burdens on the family (for travel costs, lost work time, or child care expenses) can also be significant.29 Canada is not an exception to the high prevalence and impact of RSV disease. During recent RSV seasons in Canada, the average annual hospitalization rate because of RSV disease was estimated to be as high as 2,100 per 100,000 in infants ,6 months of age. 30 By comparison, hospitalization rates attributed to inf luenza during this same time period were lower regardless of age group, with the highest rates of i nfluenza-associated hospitalizations seen among infants six to 11 months of age (200 per 100,000).30 Remote communities in northern Canada, in particular, have some of the highest rates of RSV-associated hospitalizations in the world.31 A retrospective study of the northern Canadian communities examined hospitalization rates because of LRTI in infants and found that 29 percent of all admissions tested positive for RSV. 31 In this study, the hospitalization rate from an almost exclusive Inuit population was a remarkable 590 admissions per 1,000 live births.31 SEASONALITY OF RESPIRATORY SYNCYTIAL VIRUS INFECTIONS The timing of the RSV season and peak incidence of infections varies substantially by geographic region. In countries like Canada and the United States with a temperate climate, most RSV infections generally occur in the winter months, between December and March (Figure 1).32–34 Warmer regions are often associated with an earlier onset and/or longer duration of the RSV season.35 Tropical and subtropical regions generally experience peak periods of RSV infection during the first half of the year, sometimes in association with the rainy season; however, timing is quite variable and in some countries, RSV outbreaks occur year-round.36–39 The World Health Organization has published methodologies to assist in the diagnosis of RSV infection, surveillance of RSV-related LRTIs, and determination of seasonal variations in RSV outbreaks.4 Surveillance programs are critical to help anticipate future onset of the RSV season and control RSV outbreaks through timed implementation of infection control measures and programs that supplement year-round educational initiatives. RISK FACTORS FOR ACQUIRING RESPIRATORY SYNCYTIAL VIRUS AND/ OR DEVELOPING SERIOUS RESPIRATORY SYNCYTIAL VIRUS DISEASE Although all infants and young children are at risk for acquiring RSV and developing subsequent respiratory disease, certain demographic, clinical, and environmental risk factors are associated with increased risk (Table 1).35 The number of patients with these risk factors is large. For prematurity alone, 8 percent (.30,000) of the 376,000 infants born in Canadian hospitals between 2009 and 2010 were born before 37 completed weeks’ gestation.40 It is important to note that even in children without these additional risk factors, serious RSV disease is still a significant cause of hospitalization. In a large surveillance study of U.S. children ,5 years of age, only 34 percent of hospitalizations caused by documented RSV infection were in children with high-risk medical conditions, including prematurity (,36 weeks’ gestation) and chronic pulmonary, cardiac, kidney, or immunodeficiency disease.41 This suggests that strategies and education targeting only these “high-risk” children may not adequately impact the overall burden of RSV infection.41 In this review article, we share our perspectives on strategies to prevent the spread of RSV and reduce the risk of serious RSV disease among all infants and young children, including effective approaches for education of health care staff and caregivers. Useful educational tools and additional resources can be found in a companion article in this special issue.42 REDUCING THE RISK OF RESPIRATORY SYNCYTIAL VIRUS INFECTION IN CANADA The Role of the Nurse in Education In the Canadian health care system, nurses play a central role in the education of families, caregivers, and health care N E O N ATA L N E T W O R K 358 NOVEMBER/DECEMBER 2012, VOL. 31, NO. 6 FIGURE 1 n National trends in RSV antigen detection in (A) Canada (September 2009–August 2010) and (B) the United States (November 2010–October 2011).33,34 A. Canada Total Tests December–March 7500 30 5000 20 2500 10 0 0 9-05-09 10-03-09 10-31-09 11-28-09 12-26-09 1-23-10 2-20-10 3-20-10 4-17-10 5-15-10 6-12-10 7-10-10 Percentage of Positive Tests 40 10000 8-07-10 B. United States Percentage of Positive Tests 30 25 Antigen Detection Virus Isolation 20 December–March 15 10 5 11 11 9- 5- -2 10 -1 1 -1 10 -1 -1 1 10 11 17 3- 9- -1 1 9- 11 20 6- 8- -1 1 8- 11 23 9- 7- -1 1 7- 11 25 6- -1 1 11 - 6- -1 1 28 5- -1 1 14 30 4- 5- -1 1 11 16 2- 4- -1 1 4- 11 19 5- 3- -1 1 3- 11 19 5- 2- -1 1 2- 11 22 1- 10 8- 1- 10 5- 12 -2 0 12 -1 1- -1 -1 11 - 13 11 - 27 0 0 Abbreviation: RSV 5 respiratory syncytial virus. staff. Nurses have regular contact with patients and caregivers and this hands-on experience, including education and counseling of families, can be shared with colleagues. Bedside nurses in particular, through their direct contact with families, can establish a unique bond and strong level of trust— characteristics that are often essential for effective counseling and education of caregivers. This relationship allows for more effective one-on-one counseling, as well as education by the broader health care team to better meet the learning needs of the caregivers. It is important to note that in Canada, which consists of ten different provinces and three territories, expansive TABLE 1 n Demographic, Clinical, and Environmental Factors That Increase the Risk of Acquiring RSV and/or Developing Serious RSV Disease Demographic Factors birth102–104 • Premature • Male gender105,106 • Low birth weight for gestational age107 • ,12 weeks of age at start of RSV season102,104 • Twins or higher multiples108 Clinical Factors Environmental Factors conditions109–112 • CLD, other respiratory • CHD, cardiac anomaly6,111,113 • Cystic fibrosis112,114 • Down syndrome115,116 • Neuromuscular disease112,117,118 • Immunodeficiency117,119 • Congenital malformations*,112,120 • Day care attendance104 • School-age siblings102,121 • High number of people in the home or sharing a bedroom105,108 • Lack of breastfeeding121 • Tobacco smoke exposure102,122,123 • Use of wood burning stoves†,124,125 • Nosocomially acquired RSV6,126 Abbreviations: CLD 5 chronic lung disease of prematurity; CHD 5 congenital heart disease; RSV 5 respiratory syncytial virus. *Includes spina bifida without anencephaly; cleft lip and palate; agenesis; hypoplasia; dysgenesis of the lung, larynx, trachea, and bronchi; malformations of the gastrointestinal tract and urinary system; and biliary atresia.112,120 †Studies demonstrated an increased risk of lower respiratory illness (not specific to RSV-associated disease). N E O N ATA L N E T W O R K VOL. 31, NO. 6, NOVEMBER/DECEMBER 2012 359 networking among nurses has been a critical component of the development of national, regional, and local RSV educational programs. This collaboration and networking allows sharing of best practices, access to updated health care information and research, and knowledge of policies and procedures at other hospitals, clinics, and/or physicians’ offices that can be applied broadly. National, regional, and local pre- and post-RSV season meetings among nurses and other health care providers serve as an effective forum for establishing contacts and expanding the health care network, building on existing educational and risk reduction programs, and discussing needs for future research initiatives. KEY INFORMATION REGARDING RESPIRATORY SYNCYTIAL VIRUS INFECTION AND RISK REDUCTION STRATEGIES Whether a nurse or other health care provider is responsible for education, it is important that ongoing instruction and educational materials regarding RSV infection and risk reduction be provided to both health care staff members as well as caregivers with young children. Key areas of focus should include (a) strategies for reducing the spread of RSV in the hospital and the home, (b) mechanisms of viral transmission, (c) recognition of symptoms of RSV-related disease, and (d) strategies to cohort and isolate children when there is an RSV infection. It is also important to emphasize that RSV infection does not confer protective immunity and children may become re-infected, most often before the age of 24 months.43 In older children and adults, the symptoms of RSV infection are generally mild and cold-like (e.g., cough, low-grade fever, stuffy or runny nose) and appear within four to five days. 2,3,44 As discussed, all infants and young children are at risk of developing RSV disease; however, those with certain risk factors have increased susceptibility to development of LRTIs, such as bronchiolitis and pneumonia.35 Severe symptoms include high fever, nasal f laring, severe cough, wheezing, difficulty breathing and/or shortness of breath, apnea, and hypoxia with possible cyanosis. 2,3,44,45 Infants often seem irritable, listless, and have a decreased appetite because of these symptoms, predominantly because young infants are obligatory nasal breathers and congestion of the nares impedes normal coordinated sucking and swallowing activity.2,3 Caregivers should be educated to recognize the more severe signs of RSV disease that require immediate medical attention, such as apnea, tracheal tug, nasal flaring, grunting, wheezing, apparent lethargy, difficulty feeding, and cyanosis.2,46 Respiratory syncytial virus is actively shed in saliva and nasopharyngeal secretions from infants and young children with LRTIs.47 These secretions contain high levels of the virus, which last from several days up to three weeks.47 Viral spread occurs most commonly by direct hand-to-hand contact. Indirect transmission is also possible; for example, touching a surface contaminated with droplets of infected nasal or oral secretions from a cough or sneeze.48 The virus remains stable for up to seven hours on nonporous surfaces and approximately 10–20 minutes on skin.49 Strategies for reducing the risk of spreading RSV infection can be tailored for various settings such as the home, day care, hospital, or physician’s office or outpatient clinic (Figure 2). Regardless of the setting, proper hand hygiene and cleaning surfaces that may be exposed to infected secretions, including handheld devices and keyboards, are important and simple steps that can be taken to reduce the risk of transmitting the virus. Because RSV rapidly gains entry through the membranes lining the eyes, nose, and mouth, individuals often become infected when they unknowingly touch infected secretions with their hands and subsequently touch these areas. Thus, the use of a catchphrase in educational materials such as “Where have your hands been and where are they going?” can be a great reminder for health care staff and caregivers to wash their hands regularly. Nurses can collaborate with infection control teams or other health care staff to develop brochures and posters on hand hygiene that are displayed year-round in public areas, such as elevators, waiting areas, and patient rooms. The toolkit in this issue provides an example poster that includes information on hand hygiene, as well as key educational points for caregivers and steps to help reduce the spread of RSV in the hospital setting. EDUCATIONAL STRATEGIES FOR HEALTH CARE STAFF Programs to educate health care staff are important for minimizing the spread of viral infections and can be directed by nurses or other health care providers. Educational campaigns related to viral risk reduction measures should take place year-round in the hospital, clinic, and physicians’ offices, but should be reemphasized just prior to and during the RSV season (e.g., November–March in Canada). These campaigns, which can be extended to other settings such as day care centers, might include distribution of posters, brochures, and other educational materials, development of training websites or discussion forums, and presentation of educational programs. Recommended topics include standard practices for preventing or reducing the spread of respiratory viruses; basic infection control measures; recognition of respiratory symptoms among caregivers and staff members that would require restriction of visitors and work abstinence, respectively, to reduce viral spread; procedures for isolating patients with a viral infection; key demographic and clinical factors that may increase a child’s risk of acquiring RSV or developing serious respiratory disease; national or regional guidelines for identification of high-risk patients; and guidance for effective education of caregivers. In the hospital setting, adherence to basic risk reduction strategies (see Figure 2) has been demonstrated to successfully reduce RSV nosocomial infections.50 Such strategies, which should align with hospital infection prevention policies, include diligent hand hygiene with any patient contact; N E O N ATA L N E T W O R K 360 NOVEMBER/DECEMBER 2012, VOL. 31, NO. 6 FIGURE 2 n Strategies to reduce the risk of acquiring and/or transmitting RSV. In the Home ✓ Practice good hand hygiene. Wash hands thoroughly with soap and warm water (or hand sanitizer if hands are not soiled) before touching an infant ✓ If possible, avoid day care ✓ If possible, avoid crowded areas ✓ Breastfeed infants ✓ Avoid exposure to tobacco smoke ✓ Avoid travel (especially by air) during the RSV season ✓ Clean/sanitize toys and books regularly If RSV infection occurs: ✓ If caregivers are sick, minimize close contact (avoid kissing) and always wash hands before touching the infant/child ✓ Try not to share toys when one child is ill–clean toys before any sharing ✓ Keep infant/child away from those who are sick ✓ Do not allow visitors who are sick In the Hospital ✓ Practice good hand hygiene– In the Clinic/ Physician’s Office ✓ Practice good hand hygiene– before and after any patient contact before and after any patient contact ✓ Educate caregivers on hand ✓ Educate caregivers on hand hygiene; encourage breastfeeding; discuss other strategies for risk reduction hygiene; encourage breastfeeding; discuss other strategies for risk reduction If RSV infection occurs: ✓ Follow appropriate infection control guidelines ✓ Promptly identify and isolate any infant, child, adult patient, or caregiver with any cold or respiratory symptoms (e.g., sneeze, cough, runny nose, fever) ✓ Promptly screen/test to identify the specific virus ✓ Once the virus is isolated, cohort patients and staff, if possible ✓ Wear gloves, gowns, and masks when there is a respiratory infection; change between patient contact ✓ Restrict visitors (caregivers should not visit the hospital unless healthy) ✓ Clean/sanitize toys and books regularly–ideally, have caregivers bring their own toys and books to the child’s appointment ✓ Routinely disinfect other susceptible surfaces (i.e., those exposed to hand contact or droplets from infected coughs) in the waiting room and office If RSV infection occurs: ✓ Follow appropriate infection control guidelines ✓ Promptly identify and isolate all persons with respiratory symptoms (including patients and caregivers) ✓ Wear gloves, gowns, and masks when there is a respiratory infection; change between patient contact Different measures of infection control are relevant for various settings, as shown. In each case, emphasis on good hand washing techniques is important because this is the primary means for reducing the spread of RSV. If RSV infection does occur, separate measures are recommended for reducing further transmission. Abbreviation: RSV 5 respiratory syncytial virus. immediate isolation of patients at the first sign of respiratory illness such as cough, runny nose, fever, apnea, and wheezing; restriction of visitors; protective measures when isolation is required (wearing of gloves, gowns, and masks and changing between patients); and cohorting of hospital personnel to care for isolated patients.51,52 Infectious respiratory secretions are easily spread by patients, caregivers, and health care staff in a hospital setting. Although specific barrier methods for isolation of RSV-positive patients vary, a study of Canadian pediatric hospitals found that in all cases, patients were isolated to a single room or cohorted with other RSV-positive patients to avoid further spread of infection.53 Educational campaigns regarding RSV risk reduction should be conducted in accordance with general infection prevention policies, whether in a hospital, physician’s office, or clinic. Consistent with national recommendations, these policies provide specific information on, for example, various types of infections, possible routes of transmission, and the necessary duration of precautionary measures; proper hand washing techniques; use of personal protective equipment (e.g., gowns, gloves, masks); techniques for disinfecting, sterilizing, or cleaning infected surfaces, toys, and so forth; and identification of patients who require isolation. Many resources are available to provide guidance on general infection prevention in various health care settings, including policies and recommendations from the Public Health Agency of Canada,54 the Canadian Paediatric Society, 55 the Centers for Disease Control and Prevention,56,57 and the American Academy of Pediatrics.58 N E O N ATA L N E T W O R K VOL. 31, NO. 6, NOVEMBER/DECEMBER 2012 361 SPECIFIC RISK REDUCTION STRATEGIES FOR CAREGIVERS Education of family and caregivers by nurses or other health care providers is critical to minimize the spread of respiratory infections both in the hospital and once the child is transferred home. The incidence of RSV infection is greatest during the winter months in Canada and other temperate climates, but strategies to reduce the risk of any viral infection should be emphasized all year. Educating families regarding simple strategies for minimizing exposure to RSV is imperative. In addition to training on hand-washing techniques, caregivers should be reminded not to bring any infant or young child, especially those who are at high risk of acquiring RSV or developing serious respiratory disease, to places where many people frequent or where exposure to other sick individuals (children or adults) might be difficult to avoid, such as day care or family gatherings. Because crowded areas cannot always be avoided, care providers should be counseled on strategies to minimize the possibility of RSV transmission in these settings. Written educational guides, such as the Family Teaching Toolbox59,60 shown in Figure 3, can be provided to caregivers year-round, in addition to instituting educational sessions to review the materials and help answer any questions they may have. Such educational guides should concisely summarize the most critical information about RSV, modes of viral transmission, clinical symptoms and consequences of infection, strategies to reduce the risk of acquiring or spreading RSV, and resources for additional information. FIGURE 3 n Sample RSV educational guide: the Family Teaching Toolbox. A portion of the RSV Parent Education and Communication Toolkit, developed by Bracht et al.,60 is shown. The entire toolkit consists of three informational letters provided to caregivers prior to and during the RSV season, each of which is accompanied by an educational pamphlet. The Family Teaching Toolbox portion of this pamphlet provides an overview of RSV, its symptoms, preventative measures, and resources for further information. Abbreviation: RSV 5 respiratory syncytial virus. Adapted from Bracht M, Heffer M, O’Brien K. Family teaching toolbox. Preventing respiratory syncytial virus (RSV) infection. Adv Neonatal Care. 2005;5(1):50–51. Copyright by the National Association of Neonatal Nurses. Reprinted with permission. N E O N ATA L N E T W O R K 362 NOVEMBER/DECEMBER 2012, VOL. 31, NO. 6 IMPORTANT CONSIDERATIONS FOR EFFECTIVE COUNSELING AND EDUCATION OF CAREGIVERS Low Literacy Skills Written information is an important component of the education of the infant’s caregivers. Literacy skills are necessary to understand medical information that is often complex or specialized; for example, clinical and demographic risk factors for RSV disease, recognition of LRTI symptoms, potential adverse health outcomes, and risk reduction measures. Suboptimal literacy presents a significant challenge for health care providers in effectively educating caregivers. Importantly, the inability of caregivers to adequately read and comprehend medical information may translate into decreased use of risk reduction measures, reduced adherence to treatment regimens, and subsequently poorer health outcomes for their child/children.61–63 Lack of understanding because of low literacy skills may be compounded by other factors, such as anxiety or stress often associated with making health care decisions.64 Many infants or young children who are at high risk of acquiring RSV and/or developing serious respiratory illness have other underlying clinical conditions that may heighten this level of anxiety. Although literacy rates vary by country, both literacy and health literacy, which are separate but related measures, are considered suboptimal among adults in many regions of the world. For example, in Canada, approximately 9 million people between the ages of 16 and 65 years are estimated to be at a low literacy level, with overall rates varying substantially among the different Canadian provinces.65 In particular, 60 percent of people older than the age of 16 are considered to be “health illiterate” based on standard criteria such as the International Adult Literacy and Skills Survey health literacy scale.65 Similarly, a recent survey of American adults (.16 years of age) found that approximately 40 percent of participants were at a basic or below basic health literacy level.66 Skill levels in these categories ranged from a demonstrated understanding of written information when presented in short prose text and simple documents to complete illiteracy in the English language.66 It is important for health care providers to acknowledge that family members or other care providers with low literacy skills may be too embarrassed to ask for assistance in interpreting written medical information. Thus, educational materials should consistently be prepared with low-literacy readers in mind. A good policy for preparing educational brochures or other written materials is to use plain language, avoid technical jargon, and minimize the use of statistics.67 Materials should be written at a sixth-grade reading level or less68 and incorporate symbols, pictograms, and illustrations whenever possible to improve understanding.69 This so-called “plain language approach” ensures that the most pertinent information is provided in a concise, easy-to-read format.64 Having the infant’s caregivers participate in the development of educational materials may increase their use and help ensure broader understanding.70 Numerous tools and resources are available to provide guidance in the preparation of educational materials appropriate for patients or care providers with low health literacy. Helpful resources include a plain language thesaurus71 and “Simply Put” guide72 available from the U.S. Centers for Disease Control and Prevention, which provide simplified medical terminology for the development of written and verbal communication materials targeted to nontechnical audiences. A recent comprehensive review article by Menghini73 outlines strategies for the development of educational tools specific for caregivers of infants in the NICU. These recommended strategies, many of which can be applied broadly to the health education of caregivers, are centered on the need for written materials to be easily readable, as well as culturally sensitive. Numerous resources are provided in this article, including health literacy websites, published family teaching tools, methods for evaluating readability of educational tools, and recommendations to assess caregivers’ reading and comprehension abilities.73 Finally, it should be noted that many initiatives are underway in Canada, at the national, provincial, and local levels, to improve health literacy using various approaches. These include programs and workshops targeted toward low-literacy caregivers, provision of health information through plain language pamphlets, preparation of educational materials written in nonnative languages, and use of nontraditional means of communication such as comic books and audiovisual media.65 CULTURAL DIFFERENCES It is clear that effective communication between health care providers and caregivers can also be impacted by cultural or ethnic differences. Whether this can be attributed to physician or patient communication behaviors, perceptual biases, language barriers, or a combination of these and other factors is somewhat unclear.74 Numerous studies have been conducted to better understand how unique cultural backgrounds of patients and their care providers might affect communication with health care providers and interpretation of medical information. In one study that evaluated cultural variations in response to end-of-life care, the authors suggest that health care providers consider potential differences in values or beliefs based on culture but maintain an individualized approach to care, avoiding inferences and stereotyping.75 Several recommended guidelines that may be helpful in a variety of clinical settings include assessing the language used to discuss the patient’s illness; considering the relevance of religious beliefs; determining who makes the decisions on behalf of the patient (e.g., a patriarch or larger social unit); taking into account political or historical context including past discrimination and socioeconomic status; considering gender, age, and power relationships within the patient’s family and in interactions with the health care team; and making use of available resources, such as community or religious leaders or professional medical translators.75 A variety of N E O N ATA L N E T W O R K VOL. 31, NO. 6, NOVEMBER/DECEMBER 2012 363 valuable resources, including culture-specific case studies, an overview of “cultural competence,” and links to various texts and references on cultural diversity in the clinic, are available through the Transcultural Nursing website (http://www.culturediversity.org/index.html). Although it is acknowledged that developing a culturally competent program is a constantly evolving process, five key elements are emphasized: (a) value diversity, (b) have the capacity for cultural self-assessment, (c) be conscious of the dynamics inherent when cultures interact, (d) have institutionalized cultural knowledge, and (e) have in place developed adaptations of service delivery reflecting an understanding of cultural diversity.76 TREATMENT OPTIONS FOR RESPIRATORY SYNCYTIAL VIRUS DISEASE Many families with infants and young children are unaware of the potentially serious consequences of RSV infection. In addition to educating caregivers on simple strategies to help reduce the risk of their child acquiring RSV or other respiratory viruses, it is also important to emphasize the potential acute and long-term clinical consequences of RSV infection and current means of treating children who develop an LRTI. Caregivers should be made aware that the onset of severe symptoms, such as difficulty breathing, wheezing, hypoxia, or lethargy, necessitates immediate medical attention and will likely require hospitalization with supportive care measures. According to current evidence-based clinical practice guidelines and comprehensive reviews,77–81 supportive care remains the primary means of treatment for bronchiolitis and routinely includes administration of intravenous fluids for infants who have difficulty feeding, clearance of nasal passages, and supplemental oxygen—mechanical ventilation may be required in the case of severe RSV disease. Numerous treatment options have been explored, including bronchodilators, systemic and inhaled steroids, steam inhalation, and antibiotic regimens, but none of these options have consistently demonstrated clinical efficacy.77,79–86 Nebulized hypertonic saline with or without epinephrine appears safe and may have benefit as an initial intervention, but further large-scale trials of this therapeutic strategy are needed.87–89 To date, there are no curative medical therapies for RSV-related LRTIs. The only antiviral therapy available in certain countries is ribavirin, but it is not routinely recommended because of the low benefit–risk ratio for most patients.79,90,91 Experimental studies involving small interfering RNAs (siRNAs), which target mRNA of the RSV nucleocapsid protein, are being explored for the active treatment of RSV infection. These drugs appear promising,92–94 but safety and efficacy need to be evaluated in large-scale randomized, controlled pediatric clinical trials. In many countries, including Canada, 95 the United States,79,96 and European countries,97–100 prophylaxis with palivizumab is the only current evidence-based medical intervention recommended to help reduce the risk of serious RSV disease in high-risk infants and young children. Health care providers should discuss with caregivers the specific eligibility criteria that are required for their child to receive palivizumab prophylaxis, means of administration, possible adverse effects, and the importance of compliance. SUMMARY: EMPIRICAL PRACTICE RECOMMENDATIONS We have emphasized in this article the important role of nurses in providing education to both health care providers and caregivers to help reduce the risks of transmitting RSV and other respiratory viruses and thus help protect all infants and young children from developing serious respiratory disease. Despite the potential for significant morbidity and mortality associated with RSV disease, very simple strategies can be employed to help reduce the spread of the virus. However, risk reduction requires effective education and year-round programs to ensure that both health care providers and caregivers understand and implement these strategies both consistently and effectively. In Canada, challenges to implementing educational programs include population disparities and large geographic distances between metropolitan areas and the many remote communities in northern regions of the country. In addition, cultural differences and language barriers hinder clear communication and understanding. Overcoming these challenges, which are certainly not unique to Canada, has become a key focus of the health care system. It has been our experience that reducing rates of RSV infection depends on three core practices: (a) educational campaigns on RSV epidemiology, seasonality, and burden of disease, and infection prevention measures targeted toward health care providers that care for infants and young children (i.e., at hospitals, pediatricians’ offices, community clinics, and/or remote outpost centers); (b) year-round education of all caregivers with infants and young children; and (c) extensive networking among nurses or other health care providers to ensure knowledge and sharing of policies, procedures, best practice recommendations, and ongoing research. In many provinces in Canada, RSV educational programs are generally located at larger tertiary or Level II hospitals by a collaborative group consisting of a medical director or physician(s), nurse(s), pharmacist(s), and other health care staff. These programs serve as a focal point for national, regional, and local efforts to reduce the spread of RSV. In a companion article in this special issue, Bracht and colleagues101 describe some of the objectives of these programs, including the design and implementation of educational campaigns within their own hospital/clinic; overseeing the development of easy-to-read, culturally sensitive educational materials and their distribution to families across Canada; educational outreach and networking with N E O N ATA L N E T W O R K 364 NOVEMBER/DECEMBER 2012, VOL. 31, NO. 6 other hospitals, physicians’ offices, community clinics, and/ or outpost centers, especially in rural and remote regions of the country; and attendance at national, regional, and local meetings/workshops and sharing of information garnered from these meetings. In particular, networking and collaboration have been essential for broad understanding of the impact of RSV infection and optimized care for infants and young children across Canada. ACKNOWLEDGMENTS Abbott Laboratories funded the development of this article by Complete Publication Solutions, LLC. Debbie Basevitz, RN, is on the national advisory committee sponsored by Abbott Canada and received funding to attend an advisory meeting. Marianne Bracht, RN, RSCN, Marilyn Cranis, RN, and Rose Paulley, BN, have received support from Abbott Canada in the form of unrestricted educational grants in sponsorship of their respective institutional RSV programs. They have received honoraria or travel support for presentations at Abbott-sponsored professional meetings. They are on the national advisory committee sponsored by Abbott Canada and have received funding to attend advisory meetings. Bosco Paes, MBBS, FRCPI, FRCPC, has received honoraria or research support from Abbott Laboratories for his roles as consultant, coprincipal investigator, and on a speakers bureau. REFERENCES 1.Nair H, Nokes DJ, Gessner BD, et al. Global burden of acute lower respiratory infections due to respiratory syncytial virus in young children: A systematic review and meta-analysis. Lancet. 2010;375(9725): 1545–1555. 2.Coffman S. Late preterm infants and risk for RSV. MCN Am J Matern Child Nurs. 2009;34(6):378–384. 3.Mayo Foundation for Medical Education and Research. Respiratory syncytial virus (RSV). 2011. http://www.mayoclinic.com/health/ respiratory-syncytial-virus/DS00414/METHOD=print&DSECTION= all. Accessed December 12, 2011. 4.Wright PF, Cutts FT. Generic protocol to examine the incidence of lower respiratory infection due to respiratory syncytial virus in children less than five years of age. 2000. http://www.who.int/vaccines-documents/ DocsPDF99/www9906.pdf. 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Am J Dis Child. 1990;144(1):105–108. 125.Robin LF, Less PS, Winget M, et al. Wood-burning stoves and lower respiratory illnesses in Navajo children. Pediatr Infect Dis J. 1996; 15(10):859–865. 126.Simon A, Müller A, Khurana K, et al. Nosocomial infection: A risk factor for a complicated course in children with respiratory syncytial virus infection—results from a prospective multicenter German surveillance study. Int J Hyg Environ Health. 2008;211(3–4):241–250. About the Author Marianne Bracht has over 38 years of nursing experience in neonatology, both in the neonatal intensive care unit (NICU) and neonatal follow-up clinic predominantly at Mount Sinai Hospital, Toronto. Since 1999 she has served as parent resource nurse, coordinating and leading educational programs and providing support to NICU parents. She is involved in research specifically related to family-integrated care and has coordinated the NICU RSVP program at Mount Sinai since its inception in 1999. Rose Paulley has 25 years of pediatric and neonatal experience. She has been Manitoba’s RSV Prophylaxis Program Coordinator for 8 years at the Children’s Hospital in Winnipeg. Marilyn Cranis has 33 years of nursing experience and 22 years working in the cardiac program at the Hospital for Sick Children. For the past 9 years she has served as Cardiac RSV Program Coordinator. Debbie Basevitz has worked in neonatology and pediatrics for the past 49 years. She has been the nurse coordinator of the neonatal follow-up clinic at the Jewish General Hospital in Montreal since 1984 and has been the RSV Program Coordinator since 1998. Dr. Bosco Paes is Professor Emeritus, Department of Pediatrics, at McMaster Children’s Hospital, McMaster University, in Hamilton, Ontario. He was the medical director and a pioneer of the neonatal nurse practitioner program in neonatology in Canada. His current research interests focus predominantly on RSV in infants and hematology in the neonatal population. Creative Commons License This article may be reproduced, copied, and distributed for noncommercial use. For further information about this Creative Commons license visit http://creativecommons.org/licenses/by-nc-nd/3.0/legalcode. For further information, please contact: Marianne Bracht, RN, RSCN Neonatal Intensive Care Unit Mount Sinai Hospital 775 A-600 University Avenue Toronto, Ontario M5G 1X5, Canada E-mail: [email protected] N E O N ATA L N E T W O R K 368 NOVEMBER/DECEMBER 2012, VOL. 31, NO. 6
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